| Friday, January 23, 2004
"The reason for collecting, analyzing and disseminating information on a disease is to control that disease. Collection and analysis; should not be allowed; to consume resources if action does not follow."
Foege WH et al.
International Journal of Epidemiology
Epi Update Managing Staff:
John Agwunobi, MD, MBA, Secretary, Department of Health
Landis Crockett, MD, MPH, Director, Division of Disease Control
Acting Bureau Chief,
Epi Update Managing Editor
Jaime Forth, Copy Editor/ Writer
| This Week in the
Regional Seminar Set for Winter Haven
►Second in a Series -
Bureau Introduces Editor/ Writer
Influenza Breaks Out in Vietnam
|A R T I C L E S|
Jaime Forth, Copy Editor/Writer, Bureau of Epidemiology
Melanie Black, MSW, Professional Training Coordinator, Bureau of Epidemiology
Jaime Forth, Copy Editor/Writer, Bureau of Epidemiology
David Atrubin, MPH, EIS Fellow, Hillsborough County Health Department, Bureau of Epidemiology
Melanie Black, MSW, Professional Training Coordinator, Bureau of Epidemiology
Jaime Forth, Copy Editor/Writer, Bureau of Epidemiology
Angela Fix, MPH, Respiratory Disease Surveillance Epidemiologist, Melissa Covey, Influenza Surveillance Coordinator
Caroline Collins, Arbovirus Surveillance Coordinator, Kristen Payne, Carina Blackmore, DVM, Ph.D., Acting State Public Health Veterinarian, Bureau of Community Environmental Health
A recently-published health update by the Centers for Disease Control and Prevention provides guidance for U.S. physicians with patients who may require hospitalization for radiographically confirmed pneumonia or acute respiratory distress syndrome and have a travel history that includes visits to South China or close contact with an ill person who has a history of travel to the Guangdong Province of China.
The document also makes recommendations for health care providers and other officials regarding diagnostic testing for SARS. Guidelines are described online at www.cdc.gov/ncidod/sars/absenceofsars.htm.
Travel advisories and alerts have not been issued either by the CDC or the WHO for travel to China, although prudent behavior is, as always, being suggested. Direct contact with civet cats or visits to live food markets if in China should especially be avoided. For further information regarding the U.S. ban on importation of civet cats, log on to www.cdc.gov/ncidod/sars/civet_ban_exec_order.htm.
For in-depth information about current U.S. SARS control guidelines, see the CDC document, "In the Absence of SARS-CoV Transmission Worldwide: Guidance for Surveillance, Clinical and Laboratory Evaluation and Reporting" at www.cdc.gov/ncidod/sars/absenceofsars.htm.
►February Regional Seminar Set for
This program will specifically address public health surveillance and communicable disease outbreak investigations. Topics such as principles of public health surveillance, improving provider reporting, principles of field epidemiology, historical overview of emerging pathogens and an outbreak scenario will be covered in this training. On-line registration is now available and can be accessed through the Bureau of Epidemiology Internet web site: http://www.doh.state.fl.us/disease_ctrl/epi/conf/training/regform_old.htm. The class will be limited to 45 participants. CEUs will be offered to nursing, environmental health and laboratorians.
Additional information will be provided in the Epi Update and on the Bureau of Epidemiology web page. The Bureau of Epidemiology will continue to offer basic training programs in all regions of the state. If you are interested in hosting one of the training sessions or have questions related to this program, please feel free to contact Melanie Black, Professional Training Coordinator, Bureau of Epidemiology at (850) 245-4444, ext.2448 or SunCom 205-4444,ext. 2448.
We are truly excited about the potential this program offers for improving disease prevention in Florida.
If you missed the January 17th conference call between county health departments and Bureau of Epidemiology staff, we provide a short summary of the discussion here. To participate in future conference calls, simply schedule alternating Fridays on your calendar at 10:00 a.m. EST, and consult our Intranet website for the call-in number and agenda a few days in advance of the call.
Response Plans. Don Ward reported that the Bureau of Epidemiology will be working with the Regional Health co-chairs during the next several months to develop surveillance and epidemiology outbreak response plans and our bureau is doing the same in preparation for an eventual bioterrorism event. We’ll also be refamiliarizing ourselves with our pandemic plan so we’re not caught off guard if an avian flu from Asia or another area should impact us here in the U.S.
Merlin. In rare occasions, Bureau of Epidemiology staff may delete cases from Merlin. Travis McLane explained that he is working on a message that will be sent to health departments which conveys our staff person’s name, the patient’s case number and other pertinent information whenever records are removed from the system; so if there are questions regarding the eliminated records, Merlin users will know whom to contact. This project will be completed shortly.
SARS Overview. Director of the Office of Public Health Nursing Karen Eaton, and Drs. Fermin Arguello and Joann Schulte described the updated case definition for SARS promulgated by the CDC, and provided the latest news about the confirmed cases in China.
Dr. Schulte outlined questions which callers should be prepared to answer when contacting our on-call state epidemiologist to report a case of SARS: The patient’s travel history and links to the flu, whether the patient is a Florida resident or tourist, case history so influenza can be ruled out, and other pertinent facts will must be included. In addition, she announced a change in policy from last year regarding lab procedures: Samples must be collected at bedside this year. In addition, only CDC labs will perform confirmatory testing. If a SARS case is confirmed, the state health department will make all subsequent decisions.
Dr. Arguello will act as the public information officer on SARS this year. The first point of contact for testing approval and diagnostic consultation will continue to be Dr. Schulte.
Influenza Update. Angela Fix, MPH, reported a decrease in statewide influenza cases during Week 53. She also reported an increase in the timeliness and quality of sentinel physician reports.
She announced that data should now be submitted to her on Mondays. As usual, it should be relayed to her via EpiCom.
The avian outbreaks in Vietnam continue to be a concern. So far, 14 people have succumbed to the flu since October 12th. The WHO is working with Vietnamese authorities and the CDC is sending a team, plus providing enhanced surveillance of unexplained pneumonia symptoms.
Training News. Melanie Black, MSW, reminded those in attendance that January Grand Rounds will be held on January 27th at 11:00 a.m. The topic will be Inspiratory Stridor in Female Students at a High School in Tampa, Florida. The presenter will be David Atrubin, MPH, An EIS Fellow at the Hillsborough County Health Department.
The title of the February Grand Rounds, scheduled for February 24th, is Norovirus Outbreak in a Private Elementary School in St. Lucie. The presenters are Edgardo Morales, MPH, environmental epidemiologist, SLCDH, Janet Wamnes, MS, regional environmental epidemiologist, Bureau of Community Environmental Health, and Karlette Peck, MPH, PA, SLCHD, epidemiologist.
Remember that there is a new DBPR procedure for application for CEUs for training! Online submission for Grand Rounds credits will be due within 48 hours of the completion of the program.
The annual statewide epidemiology seminar will again be held in Lake Mary. This year’s dates are May 18-19. Stay tuned for details but in the meantime, the dates are firm so be sure to mark them on your calendar.
The next bi-weekly conference call will occur on January 30th. If you’d like to be placed on the agenda, contact Melanie Black or Don Ward at
Bureau of Epidemiology Grand Rounds Program
Abstract: Fifteen teenage girls from the same high school reported experiencing an inspiratory stridor (a high pitched, rattling noise coming from the larynx area upon inhalation) during the period of January 1 – October 31, 2003. Nine of these students had onset dates during the last two weeks of September 2003. The results of endoscopy procedures performed on the affected students showed varying degrees of inflammation of the mucosa just above the arytenoids. In addition to inspiratory stridor, other symptoms experienced by the ill students included shortness of breath or difficulty breathing (especially after physical activity), chest pain, headaches, dizziness, numbness and tingling of the mouth or fingers and anxiety.
Of the 15 inspiratory stridor cases, eight are members of the high school dance team, five are members of the high school band and two are not affiliated with either organization. The dance team and band members often practice and perform together, and they were all in the vicinity of polyurethane and paint fumes during a band camp held July 21-25, 2003 at the high school. The first inspiratory stridor case, however, precedes these exposures by 6 months, and two of the cases did not attend this band camp.
Additional Information: The grand rounds presentation will begin promptly at 11:00 AM, EST on Tuesday, January 27, 2004 PowerPoint slides and the dial-in number will be available on the Bureau of Epidemiology intranet website on Monday, January 26, 2004. CEUs will be provided for nursing. If additional information is needed, contact Melanie Black, MSW, Professional Training Coordinator at (850) 245-4444 ext. 2448, SunCom 205-4444 ext. 2448 or email Melanie_Black@doh.state.fl.us
In this issue, we introduce you to another of our newest staff members – our very own copy editor and writer, Jaime Forth.
Jaime was a journalism student attending college in Michigan when, bitten by the travel bug, she moved to Florida to pursue a career in international travel. In 1983, she joined the Army and served as a personnel specialist in Europe and the U.S. When a commanding officer selected her as his chief writer, her professional aspirations changed course, and after her military commitment ended, she went to work as a speechwriter and an independent political consultant in Oklahoma and then Georgia before finally returning to Florida in 1997.
Jaime edited Website content, provided public relations assistance, and edited and wrote travel brochures and other collateral materials during her five years at VISIT FLORIDA, the state’s tourism marketing corporation, before joining the Bureau of Epidemiology. In addition to her work as copy editor and writer of the weekly Epi Update, Jaime is charged with analyzing legislative bills, providing communications capabilities, writing policies, and editing the Website and other materials intended for publication. She is also vice president of marketing and development for a voiceover production and public relations company in Tallahassee, and is a published poet.
►Responding to Vaccine-preventable Diseases
This one hour satellite broadcast is intended for public health leaders and professionals from local and state government agencies, hospitals, clinics, boards of health, community-based health organizations, academic institutions, federal agencies, and others who seek to learn more about the public health response to vaccine-preventable diseases.
Panelists Bill Roper, Dean, UNC School of Public Health, Walter Orenstein, Assistant Surgeon General and Director of the National Immunization Program, CDC, Kristin Nichol, Professor of Medicine, University of Minnesota and Chief of Medicine Minneapolis VA Medical Center and Hugh Tilson, Clinical Professor, Epidemiology and Health Policy, UNC School of Public Health will discuss the effectiveness and safety of current vaccines, barriers to adult immunizations, strategies to improve the rate of immunizations and the Racial and Ethnic Disparities in Immunization Initiative (READll).
Continuing education credit will be offered for various professions based on one hour of instruction. An online registration and evaluation must be completed to receive the appropriate continuing education credit. Website: http://www.publichealthgrandrounds.unc.edu/flu/about.htm County health department site coordinators can contact Shawna Goodwin, Office of Performance Improvement (850) 245-4444 ext. 2182 or SunCom 205-4444, ext. 2182 for registration information and assistance.
Since the end of October 2003, 13 children and one adult in Vietnam have suffered from Influenza A (H5N1), causing concern among officials at WHO and CDC, and leading to a visit this week to that country by epidemiologists and lab workers from both organizations.
Of the three types of influenza known as types A, B and C, Type A is the most dangerous, causing widespread epidemics and infecting a variety of birds and mammals. A strain similar to the one discovered in Vietnam was the cause of an outbreak in Hong Kong in 1997, which originated in chickens and spread through human to human contact, ultimately causing the deaths of six individuals.
According to the WHO, the H5N1 strain responsible for the Vietnam outbreak has been partially sequenced. The genes are of avian origin, and investigators are narrowing their search to the source of the infection and the possibility of human to human transmission, although there has been no evidence so far of such. Avian flu viruses do not normally infect or circulate among humans directly. Because of this, there is little to no immunity against them.
Symptoms of avian flu in humans include muscle aches and pains, fever, coughing and sore throat, with pneumonia, acute respiratory distress, eye infections and other severe complications. Studies have shown that prescription medications approved for the treatment of influenza strains can serve as an effective preventative for humans.
Florida influenza-like illness (ILI) activity decreased statewide for the week ending January 10, 2004 (Week 01) compared to the previous weeks. Sixteen counties reported as having high ILI% activity for the week. Five counties have reported an increase in ILI activity from the previous week, sixteen counties reported a decrease and six counties remained level. Five counties did not have at least 50% of the sentinels reporting or did not report the previous week and therefore the change in activity could not be determined. Of the 18,269 patients seen by the sentinel providers during the week ending January 10, 433 were seen for influenza-like illnesses (an overall state ILI activity of 2.37%). The Florida ILI activity code reported to the Centers for Disease Control and Prevention (CDC) for the week ending January 10, 2004 was regional. Since October 2003 fourteen people (13 children and one adult) in Hanoi, Vietnam have been admitted to the hospital for severe respiratory illnesses. The World Health Organization confirmed on Monday January 19, the fifth case of an avian Influenza A (H5N1) infection. All five patients have died. So far there has been no evidence of person-to-person transmission of the virus. Health officials believe that the patients were infected with the virus through contact with the droppings of the infected birds. Approximately two million chickens have died or been culled in Vietnam due to the disease. The virus has also infected chickens in South Korea and Japan. The CDC is recommending enhanced surveillance efforts by state and local health agencies to identify patients who have been hospitalized with unexplained pneumonia, ARDS, or severe respiratory illness that have traveled to Vietnam, South Korea and Japan within ten days from onset of symptoms.
Enhanced Surveillance for Influenza 2003-2004 Season for Week 1
Influenza or ILI Outbreaks: Four counties reported outbreaks of influenza or influenza-like illness across the state. This is a slight decrease compared to the previous week in which five counties were reporting outbreaks.
Pediatric Encephalopathies: No new cases of encephalopathy have been reported to the Bureau of Epidemiology.
Pediatric Deaths: No new cases of influenza-associated deaths among those 17 years and younger were reported to the Bureau of Epidemiology during the week ending January 10, 2004.
Notes: A few counties reported a decrease in influenza-like illness (ILI) activity in walk-in clinics, hospitals and ERs.
A statewide summary of the county enhanced surveillance reports has been made available on EpiCom.
Influenza-Like Illness (ILI) Florida Summary
Seventy-eight sentinels from 73 public clinics and private offices submitted reports for 32 counties during the week ending January 10, 2004 (Week 52). Counties with the highest percentage of patients with ILI were: Santa Rosa (2.08%, with 1 of 1 sentinel locations reporting); Lee (2.32%, with 2 of 2 reporting); Okaloosa (2.47%, with 3 of 5 reporting); Palm Beach (2.67%, with 3 of 5 reporting); Pasco (2.94%, with 1 of 1 reporting); Charlotte (3.63%, with 1 of 1 reporting); Seminole (3.76%, with 2 of 2 reporting); Pinellas (4.10%, with 7 of 8 reporting); Monroe (4.17%, with 1 of 1 reporting); Broward (4.66%, with 5 of 7 reporting); Brevard (5.03%, with 3 of 3 reporting); Lake (5.49%, with 2 of 2 reporting); Polk (5.61%, with 4 of 4 reporting); Orange (6.43%, with 5 of 9 reporting); Escambia (10.08%, with 1 of 1 reporting); and Putnam (14.63%, with 3 of 3 reporting). Ten counties reported a low percentage of patients with ILI, and four counties reported no cases of ILI. A breakdown of ILI% reported for week ending January 10, 2004 by county is listed in Table .1
Laboratory Specimen Testing in Florida
Thirty-three of the 47 specimens received by the Jacksonville Central and Tampa Branch laboratories for influenza isolate testing during the week ending January 10, 2004 (Week 01) were found positive for Influenza A. Of these 33 viruses, 16 were found positive for A (H3N2), and 17 were found positive for Influenza A, unknown. These viruses came from Broward, Charlotte, Citrus, Dade, Duval, Indian River, Leon, Martin, Monroe, Orange , Osceola, Pinellas, Polk, St Johns, Volusia, and Washington counties. Culture testing continues on four of the unknown Influenza A specimens received during Week 01 that were found positive for influenza A through PCR testing. The CDC has returned results from 14 specimens collected from Florida during October and November. All were positive for Influenza A (H3N2): five were similar antigenically to the vaccine strain A/Panama/2007/99 (H3N2), and nine were similar to the drift variant, A/Fujian/411/2002 (H3N2).
From September 28, 2003 to January 10, 2004, the Florida laboratories tested a total of 530 specimens and found 196 positive for Influenza A (H3N2) and 68 that were unknown A or had culture results pending. The remaining specimens were negative for influenza. Table 2 details isolates found since September 28, 2003 by county.
Rapid Testing Performed by Private Laboratories in Florida
Reports received from non-sentinel, private hospitals and private laboratories since September 28, 2003 are summarized in Table 3.
National Influenza Surveillance
This section summarizes the weekly influenza report from the Centers for Disease Control and Prevention. More detailed information can be found at their website:
Influenza-Like Illness Report for the Week ending January 10, 2004
The proportion of patient visits to sentinel physicians for influenza-like illness (ILI) has decreased to 2.08% nationwide. This is above the national baseline of 2.5%. The percentage of patient visits for ILI continue to decrease in each of the 9 surveillance regions, and ranged from 3.4% in the Pacific region to 1.9% in the Mountain and West North Central regions. Due to wide variability in regional level data, it is not appropriate to apply the national baseline to regional level data. National percentage and regional percentages of patient visits for ILI are weighted on the basis of state population.
Antigenic Characterization: CDC has antigenically characterized two Influenza A (H1) viruses, 511 Influenza A (H3N2) viruses, and five Influenza B viruses that were submitted by U.S. laboratories since October 1, 2003. The Influenza A (H1) viruses were similar antigenically to the vaccine strain A/New Caledonia/20/99. Of the 511 A (H3N2) viruses characterized, 98 (19.2%) were similar antigenically to the vaccine strain A/Panama/2007/99 (H3N2), and 413 (80.8%) were similar to the drift variant, A/Fujian/411/2002 (H3N2). Four of the Influenza B viruses were similar antigenically to B/Sichuan/379/99 and one was similar to B/Hong Kong/330/2001.
Influenza drift variant, A/Fujian/411/2002 (H3N2), found in the United States and Europe
The Influenza A drift variant, A/Fujian/411/2002 (H3N2) predominated the Australian and New Zealand outbreaks that peaked in mid-to-late August 2003, and has been detected in many countries in the Northern Hemisphere, including the United States. The CDC expects the current U.S. vaccine will offer some protective immunity against the A/Fujian/411/2002-like viruses because these viruses are related to the vaccine strain, A/Panama/2007/99. Antibodies produced against the vaccine virus cross-react with A/Fujian/411/2002-like viruses, but at a lower level.
U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) Laboratories Report
Since September 28, 2003, 18,535 (26.8%) of the 69,052 specimens tested for influenza viruses were positive. Four thousand four hundred seventeen Influenza A (H3N2) viruses, one Influenza A (H1) virus and 113 Influenza B viruses have been identified. Weekly ratios rather than proportions are presented in the Table 4 because specimens reported positive for influenza virus each week may include specimens submitted for testing during an earlier week.
122 US Cities Vital Statistics Mortality Report
The percentage of all deaths due to pneumonia and influenza was 10.2. This percentage exceeds the epidemic threshold of 8.1 for the week ending January 10, 2004.
International Influenza Activity
World Health Organization Communicable Disease Surveillance and Response -
WHO influenza updates to date included the following items:
An Influenza A (H1) outbreak that had begun in Iceland during early October had ended by mid-November.
For more information about the WHO Communicable Disease Surveillance and Response Updates, please visit their website at http://www.who.int/csr/en/.
FluWatch Report from the Canadian Centre for Infectious Disease Prevention and Control
For more information about the FluWatch report, please visit their website
For more information about the EISS report, please visit their website at http://dev.eiss.org/cgi-files/bulletin_v2.cgi
WHO Collaborating Centre for Reference and Research on Influenza, Melbourne Australia
Australia’s winter months are from May to October. One of Australia’s biggest influenza seasons since 1998 peaked from mid to late August 2003, and by October cases of influenza had generally subsided. Influenza A (H3) viruses were cited as the primary cause of outbreaks, with little A (H1) or B viruses isolated during the season. For more information about Australian influenza, please visit the Melbourne, Australia Branch website at http://www.influenzacentre.org/ (specific article can be found at http://www.influenzacentre.org/flunews.htm#subsiding).
2002-2003 Influenza Surveillance Summaries
An international summary of the 2002-2003 influenza surveillance season (October-September) can be found on page 303 in the November 7, 2003 edition of the WHO’s Weekly Epidemiological Record (Vol. 78) at http://www.who.int/wer/2003/wer7845/en/.
WHO recommended composition of influenza virus vaccines for use in the 2004 influenza season http://www.who.int/csr/disease/influenza/recommendations2004/en/
* Reporting is
incomplete for this week. Numbers may change as more reports are received
The Bureau of Epidemiology encourages Epi Update readers not only
to register with the EpiCom system at
but to browse EpiCom and to contribute public health observations
related to any suspicious or unusual situations or circumstances as
WN Virus activity: There were 11 seroconversions reported in sentinel chickens from Collier, Indian River, Lee, Sarasota and Volusia Counties. One WN infected dead crow was also reported from Jackson County.
SLE Virus activity: One seroconversion to SLE was reported in a sentinel chicken from Charlotte County.
Wild and Captive Birds: For capture counts and historical data, go to http://www.pherec.org/DECS and click on “Arbovirus Ecology” to download the database, then the "Bird Serology" tab.
Disclaimer: Please note that data is subject to change with confirmatory information.